| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency completed a self-assessment 1/25/2023, 7/23/2023, 1/09/2024 and not within 3 to 6 months prior to the expiration date of the agency's certificate of compliance. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| The management team(Site Supervisor, Compliance Specialist and Program Specialist) were trained on the self assessments and completion of self assessment tool in regards to regulation.15(a). |
02/05/2024
| Implemented |
| 6400.68(b) | On 1/31/2024, the hot water temperature measured 142.7°F at the kitchen sink at 11:26AM and measured 123.6°F at the bathtub, in the bathroom to the right of the hallway leading to Individual #1's bedroom, at 11:31AM. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The agency purchased digital thermometers to ensure the temperature is more accurate than the prior thermometers. On 2/1/24 the temperature was turned down on he water tank and rechecked for accuracy. Kitchen sink was 115 degrees Fahrenheit and the bathroom was 117 degrees Fahrenheit. |
02/01/2024
| Implemented |
| 6400.76(a) | On 1/31/2024, the dryer lint trap was filled with multiple layers of lint. | Furniture and equipment shall be nonhazardous, clean and sturdy. | On 2/5/24, The management team was retrained with regulation 6400.76(a). On 1/31/24 the excessive let was removed by the site supervisor. |
01/31/2024
| Implemented |
| 6400.214(b) | On 1/31/2024, Individual #1's record did not include: Incident reports relating to the individual, dental examinations, dental hygiene plan, assessment, and copies of psychological evaluations. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| On 2/5/23, The management team was trained on regulation 6400.214.(b)The individuals binder was in the office and placed back in the home with the appropriate documentation assessable such as; dental examinations, dental hygiene plan, assessment, and copies of psychological evaluations. |
02/05/2024
| Implemented |
| 6400.32(n) | Individual #1's behavior support plan completed 10/01/2023 states "Staff will monitor individual's use of the internet while staff is providing support whenever he uses it for telehealth sessions, church, or zooming with his mother. Staff will visually check the area to make sure the individual is not using any internet devices in his bedroom, including laptop, social media, and internet." | An individual has the right to unrestricted and private access to telecommunications. | On 2/7/23, BSC updated and emailed the individual's Positive Restrictive Behavior Support Plan to the Support Coordinator. On 2/8/23-2/9/24-BSC reviewed the plan with the management team and the staff. Individuals information will be updated with the HRC and Restrictive Procedure Quarterly meeting minutes to continue to address his needs. |
02/09/2024
| Implemented |
| 6400.32(r)(4) | On 1/31/2024, Individual #1 had a turn privacy lock on the inside of the bedroom door, which did not allow easy and immediate access by the individual and staff persons in the event of an emergency. | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. | On 2/5/24, the management team (CEO, Site Supervisors, Site Supervisor and Compliance Specialist) were trained on regulation 6400.32(r) (4). On 2/12/24, the individuals door nobs were changed to ensure a keyed entry for the individual. |
02/12/2024
| Implemented |
| 6400.165(a) | On 1/31/2024, Individual #1 had unopened box of Ibuprofen 200mg, with instructions "Adults and children 12 years and over, take 1 caplet every 4 to 6 hours while symptoms persist, if pain or fever does not respond to 1 caplet, 2 caplets may be used, do not exceed 6 caplets in 24 hours, unless directed by a doctor." The medication was not prescribed in writing by an authorized prescriber. | A prescription medication shall be prescribed in writing by an authorized prescriber. | The Management team was trained on the 6400 regulation 2/5/2024
Staff and Site Supervisors were retrained on OTC medications completed 2/9/2024.
The Program Specialist reviewed the OTC medication record for the Individual on 1/31/2024. Verified Ibuprofen is on the OTC medication list.
The OTC sheet recopied on color paper to make sure its visible to staff and placed in the medication binder at the site 1/31/2024.
Ibuprofen added to the January prn MAR 1/31/2024
Ibuprofen added to the January prn MAR 2/02/2024 |
01/31/2024
| Implemented |
| 6400.166(a)(13) | Individual #1 is prescribed Drysol Solution 20%, "Apply topically to both feet daily for athlete's feet". During the inspection conducted 1/31/2024, Individual #1's January 2024 medication administration record did not include the name and initials of the person who administered the medication on 1/11/2024 at 8:00AM. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | The Management team was trained in the 6400.166(a)13 regulation 2/5/2024. MAR was initialed by the DCS that worked the shift 1/11/2024 on 2/1/2024. DCS was retrained on MAR documentation 2/1/2024.The Individual was assessed to self-administer selected medications once
added to his ISP: Athletes Ft AER 1% POW, Drysol SOL 20% ,Debrox ear drops 6.5%
Once the ISP is updated staff will no longer initial the self-administered
medications. |
02/12/2024
| Implemented |